Medical Ethics

Margaret Monahan Hogan

1. Medical Ethics in the Catholic Tradition
2. Principles
3. Abortion
4. Abortion (2)
5. Research Ethics: The Ethics of Research Involving Human Subjects
6. The New Eugenics: Therapy -- Enhancement -- Screening -- Testing
7. The Ethics of Cloning
8. Cloning (2)
9. Assisted Reproductive Technologies
10. Maternal-Fetal Relations
11. Issues at the End of Life
12. The Distribution of Health Care
13. Bibliography

Medical Ethics as Creative Stewardship

Homework Questions

A. The Foundations (Lectures 1 and 2)

1. Read the Oath of Hippocrates. Enumerate its duties and its limitations on the practice of medicine. What are some of the consequences for physicians who would be guided in medical practice by the Oath?

2. The care of Jesus for the vulnerable is the model for the Catholic physician. Read chapters 8 and 9 of Matthew's Gospel. How do these Gospel passages guide physicians who would model their medical practice on the ministry of Jesus?

3. The Prayer of Maimonides is often considered to contain a moral code for the practice of medicine. List some of the important elements in the prayer. What are some of the consequences for physicians who would be guided in medical practice by the Prayer?

4. Read Part One, "The Social Responsibility of Catholic Health Care Services," of the Ethical and Religious Directives for Catholic Health Care Services. List the principles enunciated there and indicate how these principles animate directives 1 through 9.

5. Read Part Two, "The Pastoral and Spiritual Responsibility of Catholic Health Care," of the Ethical and Religious Directives for Catholic Health Care Services. List the most significant ideas contained in directives 10 through 22.

6. Read Part Three, "The Professional-Patient Relationship" of the Ethical and Religious Directives for Catholic Health Care Services. Reflect on the dignity of the human person as a free creation by God in the image of God. What are the consequences for the practice of medicine? What are the consequences for the patient in the practice of medicine?

7. The natural law tradition as explicated by Saint Thomas Aquinas is foundational for medical ethics in the Catholic tradition. Describe and evaluate the Natural Law theory of Thomas Aquinas. Include in the description (a) the historical antecedents of Natural Law, (b) the remote and proximate foundation of Natural Law, (c) the specification of the first principle and precept of Natural Law, (d) the formulation of the specific principles of Natural Law, and (e) the limitations as the movement to made from general principles to contingent action, and (f) the response of the Natural Law position to any issue in medical ethics.

8. The integral goodness of an act requires that it be good in object, in intention, and in circumstances (bonum ex integra causa et malum ex quocumque defectu). Thomas Aquinas examines this principle in http://www.newadvent.org/summa/201800.htm Question 18 in the Summa Theologiae I-II. Summarize what he says in Question 18, article 4 and give an example of an integrally good act and give examples of each of the possible kinds of defect that renders an act evil.

9. The Principle of Sanctity of Human Life has been subjected to a variety of interpretations in the contemporary culture. List several interpretations and then using an example from the practice of medicine show how the different interpretations bring about different results. Which interpretation would you defend as correct?

10. Explain the principle of Double Effect and give an example of its application in contemporary medicine.

11. Explain the Principle of Totality. Include in the explanation the difference between the application of the principle to a physical entity and to a moral entity. Give an example of the application of the Principle of Totality in contemporary medical practice.

B. Abortion (Lectures 3 and 4)

1. In the assessment of the morality of an act, the object, intention, and circumstances must be considered. What is the object of abortion and why is it important to know what the object of a proposed act is?

2. Abortion as an elective medical procedure was unknown until modern medical practice. Nonetheless, from time to time, there were indications of concern for developing life in the womb. Indicate some of those significant acknowledgments.

3. The soul was posited as the active principle of human life at least from the time of the ancient Greeks. What part does soul theory play in the abortion debate?

4. Read the section on the early development of human life from fertilization until birth. Chronicle the significant development stages in the life of a new human being from sygmay until birth.

5. Define the ontogentic zero point of development and the ontogentic zero point of behavior. What is the significance of each in the development of human life?

6. Explain the following terms:
   • a. Being in act
   • b. Active and passive potentiality
   • c. Constitution and tendency of active potentiality
   • d. Natural and specific active potentialities
   • e. Remote and proximate potentialities

7. Give a summary minimal description of human life as it is present in the zygote, the fertilized ovum.

8. The notion of autonomy is a powerful notion in the contemporary culture. Present and assess its application in the culture and in the issue of abortion.

9. Develop and evaluate the notion of pregnancy as an example of lives embedded in relationship.

10. What is the notion of a person as a juristic concept?

11. Evaluate the claim the since only forty percent of human zygotes survive to become fully developed rational beings the zygote should not receive full protection of the law.

12. Explain and evaluate the theories of ensoulment as they apply in the abortion debate.

C. Research Ethics (Lecture 5)

1. Research as a function of the drive to know and medicine as an aspect of the desire to heal are opportunities for human beings to exercise creative stewardship. Assess the opportunities and limitations found in each.

2. The Tuskegee Syphilis Study had both a scientific purpose and a social purpose. Identify those purposes. Assess the study and the longevity of the study. In your assessment pay careful attention to: (a) cultural bias, (b) the availability of penicillin, (c) the provisions and acceptance of the Nuremberg Code, and (4) the research imperative.

3. Medicine as practiced under the cloud of the Nazi dictatorship provides an example of the power and perversion of the research imperative and the medical imperative exercised in the presence of a particular ideology. Assess that practice and in your assessment pay careful attention to: (a) cultural bias, (b) the research imperative, and (3) the medical imperative.

4. Read the Nuremberg Code. List its most important precepts. List the important elements in the informed consent provision.

5. In what ways is the Declaration of Helsinki an advance on the Nuremberg Code?

6. The Code of Federal Regulations guides research on human subjects in the United States. Read the guidelines found in §46.404, §46.405, §46.406, and §46.407 and list the significant regulations for research projects involving children.

7. Assess participation in research from the perspective of the Catholic tradition in medical ethics. Be attentive to the role of the researcher as well as the role of the subject.

D. The New Eugenics: Genetic Testing, Screening, and Therapy (Lecture 6)

1. The desire to improve the quality of the human race and the quality of individual members is as old as the history of mankind. Cite some significant historical and personal instances of the press of this desire.

2. The goal of genetic engineering is to contribute to the improvement of human life. This goal becomes suspicious when it becomes the tool of the state as part of a eugenics program. In the late nineteenth century and in the early twentieth century, the United States was a leader in a eugenics program that was advanced by way of non-voluntary sterilization. Indicate some of the significant moments in the history.

3. Read the excerpt by Oliver Wendell Holmes from the Buck v. Bell decision of the United States Supreme Court.
   • Part One
   • Part Two
   This statement represents an apt summary of the prevailing position of a powerful elite in the United States in the early twentieth century. What are the values contained in that excerpt?

4. Eugenics efforts in the United States exercised considerable influence on other nations. Cite and describe an example of that influence.

5. Because of its past history with non-voluntary sterilization, the United States now has in place a formidable set of protections surrounding the important right to procreate. These protections are to be found in court decisions as well as in the department of human service guidelines. Read the court-developed guidelines for the protection of the mentally incompetent in sterilization decisions. What are the provisions of these guidelines?

6. Advances in technology offer amazing opportunities in genetic engineering. Describe the four types of genetic engineering. What are the medical and ethical implications of each?

7. Advances in technology offer the opportunity for prenatal genetic testing. What are the types of genetic testing now in use? What are the medical and ethical implications of each?

8. The genetic testing of children is a particularly difficult decision. What are its problems and what guidelines are in place to protect the child?

9. Cloning and Embryonic Stem Cell Use (Lectures 7 and 8)

10. What are the three most significant recommendations found in the Scientific and Medical Aspects of Human Cloning, the report of the National Academy of the Science on cloning?

11. What are the most significant recommendations found in Human Cloning and Human Dignity, the report of the President's Council on Bioethics on cloning?

12. In order to better understand and sort out the ethical issues of cloning-to-produce-children and cloning-for-biomedical- research describe both in the ethical language of object, circumstances, and intention.

13. Describe the scientific process of somatic cell nuclear transfer (SCNT) that is the current method of cloning.

14. What are the most significant ethical elements in the issue of cloning to produce children?

15. Examine the excerpt from the statement of Professor Lawrence Tribe. What values are embedded in that statement?

16. The experiment of cloning-to-produce-children must be carried out in accordance with the norms governing experimentation on human subjects. What provisions of those codes apply here?

17. What are the potential harms and injustices to prospective offspring who might be cloned? What are the potential benefits?

18. What are the potential harms and injustices to women who might take part in the cloning process? What are the potential benefits?

19. What are some of the potential harms and injustices to families and society as a consequence of the acceptance of cloning? What are the potential benefits.

20. If cloning-for-the production-of-children is violative of your religious principles, why is this so?

21. One of the purposes of cloning-for-biomedical-research is the removal of stem cells from the inner cell mass of the embryo. The removal of the inner cell mass causes the destruction of the embryo. The ontological status of the embryo is, then, a critical issue in assessing the morality of the process. List and evaluate the three positions found in contemporary bioethical literature on the status of the embryo.

22. What are some of the sources of stem cells and why are stem cells so valuable?

F. Assisted Reproductive Finality (Lecture 9)

1. What are the significant pressures that have influenced medical science to develop assisted reproductive technologies?

2. What are the different types of assisted reproductive technologies (ART) currently available?

3. Define the following:
   • a. Ovarian hyperstimulation
   • b. Homologous insemination
   • c. Heterologous insemination
   • d. In vivo fertilization
   • e. In vitro fertilization
   • f. Gamete intrafollopian transfer (GIFT)
   • g. Zygote intrafallopian transfer (ZIFT)
   • h. Intracytoplasmic sperm injection (ICSI)
   • i. Embryo micromanipulation
   • j. Assisted hatching
   • k. Traditional surrogacy
   • l. Gestational surrogacy

4. What are the essential elements of the Catholic tradition regarding marriage that serve to guide the accomplishment of the reproductive finality?

5. Within the Catholic tradition what is the sign that signifies the meaning of marriage. What is the sign that signifies and contains the reality of marriage? What is to be understood from these signs?

6. What are the essential elements in the Catholic teaching on marriage from Casti connubii of Pope Pius XI to Familiaris consortio of Pope John Paul II?

7. Read Directives 38-42 in Part Four, "Issues in Care for the Beginning of Life", of the Ethical and Religious Directives for Catholic Health Care Services. What guidelines are set down there for married couples in accomplishing the reproductive finality of marriage?

8. What are the significant potential harms for offspring, for women, for the family, and for society in the use of ART processes?

9. What social justice issues are pressing in the development and use of ART technologies?

G. Maternal / Fetal Relations (Lecture 10)

1. Feminism has a set of significant values that have brought about many advances for women and for society. What are they?

2. What are the features that distinguish equity feminism from equality feminism?

3. The United States Supreme Court decisions Roe v. Wade and Doe v. Bolton have had a significant influence on defining the maternal fetal relationship. Describe and evaluate those provisions.

4. Describe pregnancy as a relationship between two developing human beings.

5. Examine and evaluate the justification for abortion from the perspective of a gender equity feminist. Describe and evaluate the justification for abortion from the perspective of a gender equality feminist.

6. Read the Introduction and Directives 48-54 in Part Four, "Issues in Care for the Beginning of Life", of the Ethical and Religious Directives for Catholic Health Care Services. What guidelines are set down there to assist pregnant women and their children?

7. The Principle of Double Effect is used to sort out complex moral issues some of which arise in pregnancy. Among those issues are the rare but real risk to the life of the mother and the occasional need of a pregnant woman to receive medical treatment necessary for the continuation of her life and health. How is the Principle of Double Effect to be applied in these instances?

8. Abortion is sometimes suggested as a remedy for fetal deformity. Evaluate this remedy. In your evaluation consider the distinction between a condition of disability and a condition incompatible with life.

9. Abortion is sometimes suggested as a remedy for a pregnancy that resulted from rape or incest. Evaluate this proposed solution and its application to human beings who might become disabled at some time in the course of their life.

10. Examine and evaluate the issues for pregnant women and companies who would employ them in the contemporary cultural milieu.

H. Issues at the End of Life (Lecture 11)

1. Describe the transitions in death and dying in the modern era and the shifting human assessment of the gains and losses found in the transitions.

2. In the search for a new construct to enable human beings to deal with dying and death, the Patient Self-Determination Act became law. What are its advantages and disadvantages?

3. Physician Assisted Suicide has been suggested as an appropriate remedy to the restraining of death. Develop and evaluate the set of arguments that have been brought forth in its defense. Be certain to include the following:
   • a. Legal arguments
   • b. Philosophical arguments
   • c. Medical arguments
   • d. Practical arguments
   • e. Economic arguments

4. Against the right to assistance in suicide by medical personnel as a liberty right, there are asserted rights and obligations of the state. What are the Parens patriae obligations of the state?

5. Read the Introduction and Directives 55-66 in Part Five, "Issues in Care for the Dying," of the Ethical and Religious Directives for Catholic Health Care Services. What guidelines are set down there to assist health care practitioners in the care of the dying?

6. How should a Christian prepare for death? What obligations do Christians owe the dying?

I. The Distribution of Health Care (Lecture 12)

1. Read the text in the Gospel of Luke at 14:13. What does the text have to say about health care in the Catholic tradition?

2. What are some of the most important challenges to the delivery of health care? Include in your discussion economic, legal, political, medical, and ethical challenges.

3. In discussions of the delivery of health care, the question as to whether health care ought to be regarded as a right or as a commodity if often raised. Assess the proffered disjunction and offer an appropriate approach to the distribution of health care.

4. If health care is a scare or limited resource, how, given human nature, can we best deal with its limitations?

5. Return to the distinction between ordinary care and extraordinary care found in Directives 56 and 57 in Part Five, "Issues in Care for the Dying," of the Ethical and Religious Directives for Catholic Health Care Services. How does this distinction serve to guide the use of medical interventions?

6. Medical resources have as their primary application (a) to cure illness, (b) to assuage suffering, and (c) to compensate for disability. Assess the restrictions that ought to apply to both individuals and to the medical profession in the use of the limited resources of medicine.

7. How ought individuals and the medical profession respond to the use of the art of medicine to serve the desire for human enhancement?

8. What considerations are significant in order to put into place appropriate structures to serve the health care needs of citizens?

9. Read Catholic Health Care Institutions: Dinosaurs Awaiting Extinction or Safe Refuge in a Culture of Death. What significant points are made as to how Catholic health care can provide witness to the values it holds in the contemporary world?

Additional Readings